The heart rate is controlled by the opposing actions of sympathetic and parasympathetic nerves and by the action of epinephrine released from the adrenal gland. Norepinephrine, released by sympathetic nerves in the heart, and epinephrine, released by the adrenal gland, increase the heart rate, whereas acetylcholine, released from parasympathetic nerves, decreases it. A competitive antagonist that acts to inhibit the stimulating action of norepinephrine on the heart is propanolol, which slows the heart and is often used to treat anginal attacks and disturbances of cardiac rhythm. Atropine blocks acetylcholine receptors and is used during anesthesia to prevent excessive cardiac slowing.

There are a number of drugs that are useful in treating abnormalities in heart rate. Reentrant rhythm and ectopic pacemakers cause abnormally high heart rates (tachycardia), and they require treatment with drugs that slow the heart and reduce the electrical excitability of the muscle cells. Reentrant rhythms can be eliminated by increasing the refractory period of the cells, which is the interval following transmission of an electrical impulse during which the cell cannot be reexcited by another impulse. Increasing the refractory period has the effect of reducing the frequency at which impulses can be transmitted.

Quinidine, procainamide, lidocaine, and phenytoin exert their antiarrhythmic effects by reducing electrical excitability. Quinidine and procainamide have the disadvantage that they reduce the force of contraction of the heart and tend to lower blood pressure. They are also liable to cause side effects such as nausea and skin rashes. Lidocaine, which is also used as a local anesthetic, has a very short duration of action and must be given intravenously; its main use is in the prevention of ventricular arrhythmias following acute occlusion (blockage) of a coronary artery.

An important factor tending to exacerbate ectopic pacemakers is the release of norepinephrine from sympathetic nerves. Norepinephrine acts on beta-adrenoceptors in the heart to increase its rate, which strongly increases the tendency for ectopic pacemakers to develop. Beta-adrenoceptor-blocking drugs (e.g., propranolol), commonly known as beta-blockers, are widely used to control these types of arrhythmia because they slow the actions of the heart. They also tend to reduce the force of contraction of the heart, which can be a disadvantage, and they produce various other unwanted effects.

In the mid-1970s the calcium channel blockers, another type of antiarrhythmic drug, were introduced. Verapamil and diltiazem are important examples of this class of drugs. They reduce the influx of calcium ions through the cell membrane, which normally occurs when the cell is depolarized. This movement of calcium ions across the membrane appears to be important in the genesis of reentrant rhythms and ectopic heartbeats. Inhibiting the influx of calcium ions is effective in controlling many types of arrhythmia. Since calcium entry is essential for initiating the contraction of heart muscle cells, calcium channel blockers tend to impair muscle contractility. Since calcium entry is also important in the contraction of blood vesselsmooth muscle, these drugs cause vasodilation and tend to lower arterial blood pressure.

All the antiarrhythmic drugs discussed so far impair the conduction of the impulse for contraction from atria to ventricles and therefore can cause heart block. Antiarrhythmic drugs should be used carefully to avoid the various hazards and side effects that they may produce. Heart block causes a pathological slowing of the heart and is not usually treated with drugs, although beta-adrenoceptor agonists such as isoproterenol are sometimes used in emergencies. An artificial electrical pacemaker device is usually fitted to provide effective long-term control.

Drugs affect blood vessels by altering the state of contraction of the smooth muscle in the vessel wall, altering its diameter and thereby regulating the volume of blood flow. Such drugs are classified as vasoconstrictors when they cause the smooth muscle lining to contract and vasodilators when they cause it to relax. Drugs may act directly on the smooth muscle cells, or they may act indirectly—for example, by altering the activity of nerves of the autonomic nervous system that regulate vasoconstriction or vasodilation. Another type of indirect mechanism is the action of vasodilator substances that work by releasing a smooth muscle relaxant substance from the cells lining the interior of the vessel. Some drugs mainly affect arteries, which control the resistance to blood flow in the vascular system, an important determinant of the arterial blood pressure; others mainly affect the veins, which control the pressure of blood flowing back to the heart and hence the cardiac output (i.e., the volume of blood pumped out by the heart per minute).

Apart from the actions of the autonomic nervous system, several other physiological mechanisms regulate vascular smooth muscle. Of particular pharmacological importance are the renin-angiotensin system and locally acting vasodilator substances, such as histamine, bradykinin, prostaglandins, and nitric oxide.

Renin is an enzyme that is released into the bloodstream by the kidney when the blood pressure falls. It acts on a plasma protein to produce a peptide, angiotensin I, which consists of a chain of 10 amino acids. This in turn is acted on by angiotensin converting enzyme (ACE) to produce an eight-amino-acid peptide, angiotensin II (a potent vasoconstrictor), which raises the blood pressure. ACE inhibitors, which block the formation of angiotensin II, are used in treating hypertension, which is produced by excessive constriction of the small arteries. Drugs that block the binding of angiotensin II to its receptor can also be used.

Other drugs used in the treatment of hypertension include methyldopa and clonidine, which work at the level of the central nervous system; adrenoceptor-blocking drugs (e.g., propranolol, which lowers blood pressure by reducing the cardiac output, and prazosin, which blocks the vasoconstrictor action of norepinephrine); calcium channel blockers (e.g., nifedipine); and nitrates (e.g., nitroglycerin tablets). Hypotensive drugs, particularly nitroglycerine tablets and calcium channel blockers, are often used to relieve angina pectoris. Angina often is the result of partial occlusion of the coronary vessels by fatty deposits (atheroma) or blood clots. Hypotensive drugs reduce arterial blood pressure and cardiac output and thereby lower the work and oxygenconsumption of the heart. They also have some effect on the coronary vessels themselves, and many direct blood toward the regions in which the flow is impaired.

Most antihypertensive drugs have a variety of unwanted effects, such as drowsiness, dizziness on standing (due to an excessive postural fall in arterial pressure), impotence, and allergic reactions. Though often fairly minor, side effects are a serious problem because of the long-term nature of antihypertensive therapy, and better drugs are constantly being sought.

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